Assignment: Write a report on a mock client. Use the outline below in your repor

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Aug 10, 2022

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Assignment: Write a report on a mock client. Use the outline below in your report and address each section
Evaluation Components Outline – 400 Points ____________________________________________________________________
EVALUATION
Mock patient- you create the identity and the profile
Name:
Age:
Date of Birth:
Race:
Sex:
Marital Status
Date of Evaluation:
Date of Report: (There is often a delay before the report is ready, but generally should be within a week)
_____________________________________________________________
REFERRAL INFORMATION
Who made the referral to you and why? Typically 1 paragraph
____________________________________________________________
DATA SOURCES
What are the sources of your background information? Self-report, record review, collateral interviews.
The sections below are typically 1 paragraph each
CLINICAL SECTION
RELEVANT HISTORY
Psychosocial – info about early family life, parents, sibs, SES, conditions ?
Educational – where attended, highest level of ed, any spec ed? Behavioral issues?
Vocational –work history, # of jobs, strengths/problems?
Legal – arrest record- when, where, outcome- served when & where?
Past Medical History- history of past medical problems, surgeries, current diagnoses?
Past Psychiatric History- history of previous treatment- inpatient and outpatient, Meds prescribed?
Substance Use History-onset of use, which drugs? Alcohol? Street vs. Rx drugs? MENTAL STATUS EXAMINATION (an objective and organized review of relevant symptoms)
Appearance/Presentation – hygiene, overall appearance, neat or disheveled? Alert, cooperative? Oriented to self, time, date, and situation?
Speech – normal vs. rapid, coherent vs. garbled, tone, rate, prosody, and rhythm.
Mood/Affect – Mood is a direct quote from the patient in answer to what’s your mood? (sad, happy, depressed, etc.). Affect refers to observable mental state and is usually phrased.. His affect was appropriate to the content of his conversation- inappropriate would be a person talking about something very sad and laughing or smiling at the same time.
Thought Processes are assessed through speech- if one is speaking their thoughts… are they coherent and goal-directed vs. rambling? Is the person reporting auditory or visual hallucinations? Reporting delusions? Thought Content – what is the subject of thought? Normal vs. bizarre, atypical abnormal?
Suicidal Ideation- Is the person reporting suicidal ideas? Since when? Pervasive or episodic? Is there a fam history? Plan? History of previous gestures? What is the lethality? (this will be taught).
Homicidal Ideation Is the person reporting homicidal ideas? Since when? Toward a specific person or generally? Pervasive or episodic? Is there a fam history? Plan? History of previous violence? What is the lethality? (this will be taught).
HIGHER CORTICAL FUNCTIONING
Memory – Intact or impaired? 3 out of 3 objects? Immediate vs. delayed?
Concentration – Attentive or easily distracted?
IQ Estimate- Make an estimate of IQ
General Fund of Knowledge- Recent big news stories, Who’s the 16th President? How many weeks in a year?
Impulse Control- Based upon history and observations
Abstraction- Intact or concrete? How are North and West alike?
Judgment – Normal or poor
Insight- Normal or poor
DSM 5 DIAGNOSES
1.
2.
3.
CLINICAL FORMULATION
The above results lead to the Diagnoses, which in turn should lead to a clinical formulation as to your treatment plan. How do you conceptualize the patient’s situation and problems? What treatment plan and why?
RECOMMENDATIONS
1. What are your specific treatment recommendations and why?
2. 3. 4.

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